Bedside ultrasonography detects significant femoral vessel overlap: implications for central venous cannulation

Abstract

Objective: Our goal was to gain a better understanding of the femoral vessel anatomy as it relates to central venous cannulation. The primary objective of this study was to use bedside ultrasonography to determine the amount of exposed femoral vein at three sites corresponding to surface anatomy of the landmark-based procedure. Methods: This cross-sectional study enrolled a random sample of 180 adult patients presenting to a large urban academic emergency department. Subjects underwent standardized ultrasonography to identify and measure the depth and diameter of the femoral vessels and amount of exposed femoral vein at the level of the inguinal ligament (0 cm) 2 cm and 4 cm below. Repeated measures analysis of variance was used to determine significant relationships between vessel measurements and distance from the inguinal ligament. Results: The median age was 44.5 (range 19-90) years; 101 patients were male. The mean (6 SD) percentage of exposed vein at the inguinal ligament was 83% (6 21). This decreased significantly (p , 0.01) with increasing distance from the inguinal ligament: 65% (6 25) at 2 cm and 56% (6 30) at 4 cm. At every distance away from the inguinal ligament, there were some subjects with no vein exposed. Conclusion: This study demonstrates significant overlap of the femoral vessels at sites where landmark-based femoral vein cannulation is often attempted. Our results suggest that ultrasound guidance would be beneficial as femoral vein cannulation may be difficult or impossible in certain individuals owing to anatomic variations. RÉ SUMÉObjectif: Notre objectif é tait d'acqué rir une meilleure compré hension de l'anatomie des vaisseaux fé moraux en ce qui concerne la canulation veineuse centrale. L'objectif principal de cette é tude é tait d'utiliser l'é chographie au chevet pour dé terminer la portion de la veine fé morale exposé e à trois points correspondant à l'anatomie de surface en utilisant la technique des points de repè res. Mé thodes: Dans le cadre de cette é tude transversale, un é chantillon alé atoire, composé de 180 adultes qui se sont pré senté s au service d'urgence d'un grand centre universitaire en milieu urbain, a é té utilisé . Les sujets ont subi une é chographie standardisé e pour dé tecter et mesurer la profondeur et le diamè tre des vaisseaux fé moraux et la portion de veine fé morale exposé e au niveau du ligament inguinal (à 0 cm), à 2 cm et à 4 cm en-dessous. Une analyse de variance à mesures ré pé té es a é té effectué e pour dé terminer les relations significatives entre les mesures des vaisseaux et la distance entre la veine et le ligament inguinal. Ré sultats: L'â ge mé dian é tait de 44,5 ans (fourchette de 19 à 90 ans); 101 patients é taient de sexe masculin. La moyenne (6 s) en pourcentage de la veine exposé e au ligament inguinal é tait de 83 % (6 21). Cela diminuait de faç on significative (p ,0,01) avec l'augmentation de la distance la sé parant du ligament inguinal : de 65 % (6 25) à 2 cm et de 56 % (6 30) à 4 cm. À chaque point distant du ligament ...

Ultrasound-guided central venous catheter placement: a structured review and recommendations for clinical practice

“…These landmark techniques cannot account for anatomic variations at the CVC insertion site. Anatomic variations to the "normal anatomy", however, have been described in a relevant proportion of patients for the internal jugular vein (IJV), the subclavian vein (SV), and the femoral vein (FV) [ 3 – 11 ]. In addition to anatomic variations, venous thrombosis that is especially common in oncologic and critically ill patients can make CVC placement impossible or dangerous for the patient [ 9 ].…”

Ultrasound-guided central vascular interventions, comments on the European Federation of Societies for Ultrasound in Medicine and Biology guidelines on interventional ultrasound

“…Through technical advances and improvements of image quality, RTUS allows identification of vessel localisation the best target vessel and optimised puncture site (10). Anatomical variations can be easily identified (1)(2)(3)(4)(5) and vein thrombosis excluded which is not only of importance in oncological patients (11,12). It is important to exclude vein catheter associated thrombosis in, for example, critical care patients.…”

“…High frequency (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17) MHz, in practice 7-12 MHz) linear transducers with a relatively small aperture of less than 4-6 cm are recommended for superficial locations. In deeper locations (e.g., femoral vessels), particularly in obese or oedematous patients, the use of a curved array abdominal probe may be necessary.…”

The REBOA window: a cadaveric study delineating the optimum site for austere cannulation of the femoral artery for resuscitative endovascular balloon occlusion of the aorta

“…13 The variability of the vessels in terms of overlap is less well characterised, however existing studies confirm the tendency of the artery to overlap the vein as the vessels progress distally from the inguinal ligament, and that optimum access to the individual femoral vessels is best achieved more proximally, towards the inguinal ligament. [20][21][22] Ultrasound-guided cannulation is superior in terms of accuracy and the prevention of complications, and implementation of an ultrasound-guided approach for femoral arterial cannulation is preferable where resources permit. Active point-of-care ultrasound systems are already in use in the pre-hospital environment in the context of focused assessment with sonography for trauma (FAST), the detection of traumatic pneumothorax, and, more recently, by the London Air Ambulance for common femoral arterial cannulation in REBOA.…”